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Ultrasound Teaching Manual The Basics of Performing and Interpreting Ultrasound Scans Matthias Hofer, M.D. With the collaboration of Tatjana Reihs, M.D. Tra nslated by Peter F. Wi nter, M. D. 486 Illustrations Thieme Stuttgart· New York 1999 Matthias Hofer, M.D. Institute for Diagnostic Radiology (Chairman: Prof. U. Madder. MD.) H. Heine University DUsseldorf, Germany List of Abbreviations AC ASD BPD CRL CT d AO Tatjana Reihs, M.D. Department of Obstetrics and Gynecology H. Heine University DUsseldorf, Germany Pvc Translated by Peter F. Winter, M.D. Chlinical Professor of Radiology Boston University School of Medicine. Clinical Assistant Professor University of Illinois College of Medicine at Peoria USA Library of Congress Calaloging-in-Publicalion Data Hofer, Matthias. [Sono Grundkurs. English 1 Ultrasound Teaching Manual, The Basics of Performing and Interpreting Ultrasound Scans I Matthias Hofer : translated by Peter F. Winter. p. cm. Rev. translation of: Sono Grundkurs. 1997. Includes bibliographjcal references and index. ISBN 3-13-111041-4. - ISBN 0-86577-725-X (TNY) I. Diagnosis. Ultrasonic. I. Title. WN 208 H697s 1999J [DNLM: 1. Ultrasonography. RC78.7.U4H6413 1999 616.07'543--{]c21 DNLM/DLC for Library of Congress 98-45748 CIP Some of the product names. patents. and registered designs referred to in this book are in fact registered trademarks or proprietary names even though specific reference to this fact is not always made in the text. Therefore, the appearance of a name without designation as proprietary is not to be construed as a representation by the publisher that it is in the public domain. This book, including all parts thereof. is legally protected by copyright. Any use, exploitation or commercialization outside the narrow limits set by copyright legislation, without the publisher's con· sent, is illegal and liable to prosecution. This applies in particular to photostat reproduction, copying, mimeographing or duplication of any kind, translating, preparation of microfilms. and electronic data processing and storage. © 1999 Georg Thieme Verlag, RUdigerstraBe 14, D-70469 Stuttgart. Germany Thieme New York, 333 Seventh Avenue, New York. NY 10001, USA Typesetting by primustype R. Hurler GmbH, D-73274 Notzingen typeset on Textline/HerculcsPro Printed in Germany by Druckhaus Getz, Ludwigsburg ISBN 3-13-1 11041-4 (GTV) ISBN 0-86577-725-X (TNY) 1 2 3 4 5 6 EFW EP ERCP ESWL FHVI FL FNH GI GSD HC HCG IUD IVF MCL MRI NPO NT OFD OHVI PCOS PW RI SLE SMA SIP TGA Vol ub VSD YSD Abdominal circumference Atrial septal defect Biparietal diameter Crown-rump length Computed tomography Diameter of the aorta Diameter of the inferior vena cava Estimated fetal weight Ectopic pregnancy Endoscopic retrograde cholangiopancreatography Extracorporeal shock wave lithotripsy Frontal horn ventricular index Femoral length Focal nodular hyperplasia Gastrointestinal tract Gestational sac (= chorionic cavity) diameter Head circumference Human chorionic gonadotropin Intrauterine device In vitro fertilization Midclavicular line Magnetic resonance imaging Nothing by mouth Nuchal translucency Occipitofrontal diameter Occipital horn ventricular index Polycystic ovarian syndrome Pulsed wave Doppler Resistance index Systemic lUpus erythematosus Superior mesenteric artery Status post Transposition of the great arteries Volume of the urinary bladder Ventricular septal defect Yolk sac diameter Important Note: Medicine is an ever-changing science undergoing continual development. Research and clinical experience are continually expanding our knowledge, in particular our knowledge of proper treatment and drog therapy. Insofar as this book mentions any dosage or application, readers may rest assured that the authors. editors. and publishers have made every effort to ensure that such references are in accordance with the state of knowledge at the time of production of the book. Nevertheless. this does not involve, imply, or express any guarantee or responsibility on the part of the publishers in respect of any dosage instructions and forms of application stated in the book. Every user is requested to examine carefully the manufacturer's leaflets accompanying each drug and to check. if necessary in consultation with a physician or specialist, whether the dosage schedules mentioned therein or the contraindications stated by the manufacturers differ from the statements made in the present book. Such examination is particularly important with drugs that are either rarely used or have been newly released on the market. Every dosage schedule or every form of application used is entirely at the user's own risk and responsi. bility. The authors and publishers request every user to report to the publishers any discrepancies or inaccuracies noticed. 3 Foreword The increasing role that imaging procedures have assumed in the clinical routine must be considered at an early stage in the education of medical students. The vast use and noninvasive characler of sonography make it prudent to familiarize tomorrow's physicians today with this comparatively low-risk technology. The pilot project on medical didactics that began in Dusseldorf in 1992 consisted of preliminary lessons in sonography for a few medical students particularly interested in sonography and endoscopy. Soon, the hands-on instructions in small groups became more and more accepted and this teaching concept could be enlarged and improved. Under the guidance of residents and lecturers, student instructors relate the sonographic diagnostic to their junior students. The participants examine each other and systematically learn the anatomic relationship of the abdominal organs as seen in the standard sonographic sections. Step by step, they learn how to use and handle the transducer. lnese hands-on instructions are accompanied by complementary lectures, which address the subject of differential diagnosis of the pathologic changes by means of videos, slides, and live storm") will soon give way to increasing enthusiasm for this elegant modality. It should be pointed out, however, that each sonographic diagnosis can only be as good as the examiner. False diagnoses can only be avoided through profound anatomic and sonomorphologic knowledge, unrelenting thoroughness, and. where appropriate, comparison with other imaging procedures. Intitial successes ("1 now recognize all parenchymal organs') should not lead to overconfidencc during the learning phase; a truly profound knowledge can only be gained through long exposure in the clinical selling and the resultant practical experience that leads to the familiarization of the diverse anatomic variations and pathologic changes. This workbook. of course. cannot encompass all aspects of diagnostic sonography and this is not its goal. Instead, it should offer the reader an oplimal introduction to sonography. The spectrum of the information presented and the pathologic examples are especially targeted at the beginner. The carefully prepared didactic presentation, which reflects the author's teaching expericnce over many years, will hopefully motivate or perhaps evcn excite many students. demonstrations. The workbook presented here is largely based on the curriculum of this introductory sonography course for beginners. The approach selected here considers in particular the difficulties generally encountered by the novice. By relying on the step-by-step process of the workbook, the novice will soon realize that initial frustration ("1 only see a snow Dusseldorf Ulrich Madder, M.D. Director, Institute of Diagnostic Radiology Heinrich-Heine-University, Dusseldorf Germany 4 Introduction and Suggestions to the Reader This workbook is primarily for medical students, technicians, and residents that have had no or little exposure to sonography and wish to learn this technique systematically. The first step is recognizing the normal analOmic structures. Each section therefore begins with the anatomic orientation of the respective body region (where is the top of the image?) before presenting and commenting on a selection of the most common diseases. Before reading the individual sections, the material on pages 6 to 10 should be studied to learn the basics before the hands-on praclice. Thereafter. il is advisable to make a drawing of the body planes as seen in typical longitudinal (sagittal) as well as in typical cross (transverse) sections, for example on a cone coffee filter. The shape of the cone coffee filter corresponds to the shape of the sonographic image for the examination of the abdomen. At this stage the reader can already experience the gratifaction of successful learning. The correcl answer should not be passively copied from page 78. Instead, the anterior and dorsal structures as well as the superior and inferior structures, as seen on the sagittal section and viewed An explanatory diagram, intentionally annotated with numbers only, is placed adjacent to each sonographic image. facilitating the interpretation of the sonographic image with the help of numbers incorporated in the accompanying texl. To confirm the interpretation after the text has been studied. the back cover can be opened to use the key found on the unfolded cover page. By blocking the labels, it is easy to check whether all structures have been correctly identified. The numbers of the labels apply to all the diagrams in this workbook. If the thirst for knowledge has not yet been quenched. the quiz found at the end of each section can be tackled. The images in the quiz should be identified as to sectional orientation and visualized structures, and, if possible, a differential diagnosis provided. Only afterwards should the answers on pages 76 and 77 be consulted since the suspense is prematurely lost otherwise. The quiz may possibly arouse diagnostic inquisitiveness and lead to a first feeling of achievement through an imaging procedure. Whenever these praclical applications do not readily lend a mental concept of the imaging plane in question or the reader is confronted with other discouraging events, help may be found on pages 78 and 79. from the patient's right side, should be deduced_ TIle cone coffee filter should be placed on the abdomen and oriented along the plane of the sonographic beam of a transducer (convex border of the cone coffee filter) placed on the epigastric region along the midline (linea alba, between both reclus muscles) (Fig, 4,1 a). Next, anterior and dorsal structures as well as right and left structures should be marked on the reverse of the cone coffee filtcr as scen on the cross-sectional (transverse) sonographic image viewed from below (I) (Fig_ 4_1 b). Only after mastering the spatial orientation is the reader prepared for studying the normal findings as seen in the standard planes and. thereafter, the diffuse and focal abnormalities of the individual organs. Fig. 4.1 a Fig.4.1b 5 Contents Image Formation and Echogenicity Operating Sonographic Equipment Sonographic Equipment and Selection of the Appropriate Transducer Artifacts 6 Spleen . . . 7 8 9 Normal Findings. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. Diffuse Splenomegaly Focal Splenic Changes. . . . . . . . . . . . . . . . . . . . . . . . . .. Quiz for Self-Assessment . . . . . . . . . . . . . . . . . . . . . . . .. 47 48 49 50 1 Sa ittal Overview 7 GI Tract Upper Retroperitoneum . . . . . . . . . . . . . . . . . . . . . . . . .. Lower Retroperitoneum in Oblique Sections: Normal Findings Aortic Ectasia and Aneurysms . . . . . . . . . . . . . . . . . . . .. Retroperitoneum: Lymph Nodes. . . . . . . . . . . . . . . . . .. Retroperitoneum: Other Clinical Cases. . . . . . . . . . . . .. 11 12 13 Stomach. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. Colon '. . . . . . . . . . . . . .. Small Bowel .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 51 52 53 Normal Findings, Volume Measurements Indwelling Catheter, Cystitis. Sediment 54 55 Prostate Gland, Testicles and Scrotum Undescended Testicle. Orchitis/Epididymitis. . . . . . . . .. 56 57 Normal Findings. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. Uterus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. Tumors of the Uterus Ovaries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 58 59 60 61 14 15 2 Axial Overview Upper Abdomen: Basic Anatomy Upper Abdomen: Normal Findings Upper Abdomen: Pancreatitis . . . . . . . . . . . . . . . . .. Pancreas: Additional Cases Upper Abdomen: Lymph Nodes. . . . . . . . . . . . . . . . . .. Quiz for Self-Assessment. . . . . . . . . . . . . . . . . . . . . . . .. • 17 18 19 20 21 22 3 liver Porta Hepatis: Normal Findings. . . . . . . . . . . . . . . . . . .. Portal Hypertension: Lymph Nodes. . . . . . . . . . . . . . . .. Hepatic Vein Confluence and Hepatic Congestion. . . .. Hepatic Size. Gallbladder, Normal Findings Normal Variants. Fatty Liver. . . . . . . . . . . . . . . . . . . . . .. Focal Fatty Infiltration Other Focal Changes. . . . . . . . . . . . . . . . . . . . . . . . . . .. Infections. Parasite. . . . . . . . . . . . . . . . . . . . . . . . . . . . .. Cirrhosis and Hepatocellular Carcinoma. . . . . . . . . . . .. Hepatic Metastases Quiz for Self-Assessment. . . . . . . . . . . . . . . . . . . . . . . .. 23 24 25 26 27 28 29 30 31 32 33 11 Pre nancy Diagnosis of Early Pregnancy. . . . . . . . . . . . . . . . . . . . .. Biometry In the First Trimester Biometry In the Second and Third Trimester. . . . . . . . .. Placental Location and Fetal Gender. . . . . . . . . . . . . . .. Diagnosis of Fetal Malformations .. . . . . . . . . . . . . . . .. Quiz for Self-Assessment. . . . . . . . . . . . . . . . . . . . . . . .. 63 64 65 66 67 73 12 Th roid Gland Cholestasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. Gallstones and Polys Cholecystitis and Quiz for Self-Assessment 34 35 36 Normal Findings. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. Diffuse and Focal Changes 74 75 Solutions to the Quiz. . . . . . . . . . . . . . . . . . . . . . . . .. 76 Tips and Tricks for the Beginner . 78 Acknowledgement . 80 S Kidneys and Adrenal Glands Normal Findings. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. Normal Variants and Cysts Atrophy and Inflammation Urinary Obstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . .. Differential Diagnosis of Urinary Obstruction . . . . . . . .. Renal Stones and Infarcts Renal Tumors '. . . . . . . . . . . . . . . . . . . . . . . . .. Renal Transplant: Normal Findings Renal Transplant Quiz for Self-Assessment. . . . . . . . . . . . . . . . . . . . . . . .. 37 38 39 40 41 42 43 44 45 46 On the fold-out covers: Front: Rear: Standard Sonographic Sections Index Key to Diagrams Normal Measurements